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Forms

Important note: Most forms on this page are in PDF formatting, unless otherwise noted. Please ensure you have the latest version of Adobe Reader on your system. See lower right of this page for a link to additional information.

FREQUENTLY ACCESSED FORMS

Clinician Tax ID – Add/Update Online FormClick Here
Clinician Tax ID – Add/Update Paper FormClick Here
Clinician Tax ID – Add/Update - TennCare Medicaid Network onlyClick Here
Optum Psych Testing Form
(For KanCare, Medica and Unison Psych Forms, Click Here)
Click Here
Wellness Assessment Form (Adult, English)
Click Here
Individual Provider Disclosure of Ownership FormClick Here
Agency Specialty Attestation FormClick Here
Optum Forms - Administrative

California Grievance and IMR Forms

Clinician Application and Update Forms

Confidential Exchange of Information Form

Member Informed Consent Form (sample)

OHBS-CA Release of Information Form

Optum Release of Information Form

Patient Financial Responsibility Forms

Psychological Testing Request Forms

Site Audit Tools

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

Wellness Assessment Forms * does not apply to Unison membership

Wellness Assessments are available here, on the Forms page, at the secured user section, or by mail.

The Wellness Assessments here can be printed blank or, with the editable form, you can type in the information for the top section before printing the form.

Adult Wellness Assessment (English): blank or editable

Youth Wellness Assessment (English): blank or editable

Adult Wellness Assessment (Spanish): blank or editable

Youth Wellness Assessment (Spanish): blank or editable

WA Instruction Page:  English or Spanish

Sample completed WA: English or Spanish

WA Client Education Sheet

Wellness Assessments are also available at the secure transaction section of Provider Express for registered users!

Log in and click on the ALERT tab. Here you can print out Wellness Assessments that can be pre-populated with the name of the clinician* and member name.
*Note: A clinician number will be pre-populated on the form. For the confidentiality of those clinicians whose Tax ID is their social security number, all clinician numbers presented on these WA forms are Optum-assigned numbers.

Notes about the Wellness Assessment forms:

  • It is advised to download each Wellness Assessment rather than copy because photocopying will deteriorate the face quality of the form which could lead to technical difficulties in the ability of Optum to read the forms when you fax them to us.
  • There is only one Wellness Assessment form; it is the same one that is offered to members at the first and second time.
Optum Forms - Authorization

If the online authorization request forms are unavailable due to an outage or other system related issue, please call the number listed on the member’s ID card for assistance with an authorization.

Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Colombia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)

Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)

Optum Forms - Claims

All outpatient and EAP claims should be submitted electronically via Provider Express or EDI. For faster claims reminbursement with less hassle, it is strongly encouraged that you sign up for electronic funds transfer (EFT) via Optum Pay.

Inpatient claims may be submitted through Electronic Data Interchange (EDI) through the clearinghouse of your choice.  For paper claim submission, facilities should use the industry standard UB-04 claim form using contracted revenue codes.  

Claims that need to be filed on paper should be done on the red 02/12 1500 Claim Form. Click to see a sample 1500 form, a listing of all Optum required fields, as well as the reverse side of the 1500 Claim Form.

Click here to learn where to submit Optum Claim forms

To receive copies of the 02/12 1500 Claim Form, contact:

NJ Out-of-Network Inadvertent/Involuntary Claims Negotiation Request Form

NY State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

Optum Forms - Clinical

ASAM Levels of Care

California Grievance and IMR Forms

Confidential Exchange of Information Form

Coordination of Care Checklist

Disability Solutions Program Forms

Idaho Targeted Care Coordination

Long-Acting Injectable (LAI) Medication

Nebraska Medicaid - Audit Tools

OHBS-CA Release of Information Forms

Screening Tools - the tools below are provided as a resource to aid in the screening of alcohol and drug use.

Transcranial Magnetic Stimulation (TMS) & Electroconvulsive Therapy (ECT) Forms

 

Uniform Treatment Plans (UTP)
Fax completed UTP forms to 1-877-235-9905, unless requesting TX SB 58 Services. If requesting TX SB 58 Services, fax completed TX UTP to 1-877-450-6011

Washington (state) IMC Critical Incident Report Form

Wellness Assessment Forms * does not apply to Unison membership

 

FREQUENTLY ACCESSED FORMS

Clinician Tax ID – Add/Update Online FormClick Here
Clinician Tax ID – Add/Update Paper FormClick Here
Clinician Tax ID – Add/Update - TennCare Medicaid Network onlyClick Here
Optum Psych Testing Form
(For KanCare, Medica and Unison Psych Forms, Click Here)
Click Here
Wellness Assessment Form (Adult, English)
Click Here
Individual Provider Disclosure of Ownership FormClick Here
Agency Specialty Attestation FormClick Here

 

 

 

 

NOTE: When submitting psychological testing prior authorization requests, you may receive an incorrect submission error message. Requests are being received and reviewed, so please avoid submitting duplicate requests which cause processing and approval delays. We appreciate your patience while we work to resolve this issue.